The wrist is a bio-mechanically complex joint allowing the wrist to move in extension (up), flexion (down), radial deviation (towards the thumb), ulnar deviation (towards the small finger) and minimal degrees of rotation. view

Compartment syndrome in all extremities is an orthopedic emergency. The hand muscles are covered and divided by groups into compartments by a well defined, unyielding envelope called the deep fascia. view

An amputation is the severing of a body part. Amputations are classified as partial and complete and if the amputation was a clean cut, a crushing amputation or an avulsion amputation where the amputated limb is pulled right off of the body. view

The most frequent swelling or masses found at the hand and wrist level are ganglion cysts. view

HAND CONTUSION

Pathology

Open wounds at the hand imply the disruption of the skin with exposure of deeper structures.

Depending on the mechanism of injury, the wound can be:

Sharp lacerations from a knife or saw injuries

A crushing injury

An avulsion injury

Any combination of the above types of injuries

Open wounds can be classified as superficial when they remain above the level of the deep fascia. The deep fascia is a whitish, well-defined envelope covering the tendons, muscles, deep nerves and arteries.

A superficial wound can involve the skin, subcutaneous tissue (fat) and superficial vessels or nerves. All wounds demand immediate assessment and treatment by a trained hand surgeon to correctly identify the injured structures. A superficial wound can be treated in an emergency room setting and a hand specialist contacted to discuss a clear treatment plan. The patient should then be seen by a hand specialist for further evaluation and recommendation. Tetanus is updated if it has been longer than 10 years since receiving a tetanus shot or if the wound is a dirty wound, then the tetanus is updated if it has been five years since receiving a tetanus shot. This is to avoid the danger of acquiring gas gangrene that can be deadly. The use of oral antibiotics for one week after a repair is used as a prophylaxis to avoid the risk of infection. Special splints are applied after the procedure for comfort or protection. The injured extremity must be elevated to at least heart level to avoid swelling of the limb that can cause moderate pain, cut off the blood supply and delay wound healing.

Some of these cases will require urgent exploration, debridement (surgical cleaning that is deeper and more thorough than a regular wash out in the emergency room), and repair of superficial nerves. This should be done as soon as possible within a week time from injury. Some of these cases may require only close observation for the wounds to appropriately heal if the physical exam indicates that the tendons, nerves and vessels are intact.

A deep wound can involve the above mentioned structures and a number of deep tendons, muscles, nerves and arteries. The degree of contamination, the extent and severity of the injury will demand different urgency of treatment that only a qualified health care professional can appropriately assess. Emergency treatment of a deep wound can receive initial cleaning by a emergency health care professional, and any bleeders can be controlled at that time by gentle pressure or by direct suturing and the laceration can be closed after a thorough preliminary assessment has been done and a hand specialist has been contacted to discuss appropriate definitive treatment recommendations. Many of these injuries can be referred to a hand specialist for further evaluation and recommendations in an URGENT within a one week time. At ROC, however, we also offer emergency treatment of the injury if the patient is ready to proceed with surgery and has the appropriate medical clearance to have the surgery performed.

Some patients may present with severe contamination, incontrollable bleeding, presence of a foreign body (glass), a pulseless extremity (that is at the highest risk for loosing tissue), open joint or other associated injuries like an open fracture that demand EMERGENT surgical care the moment it presents. In these cases the patients need to be stabilized, the hand specialist needs to be contacted immediately to communicate the emergent need of attention and organize appropriate routes and locations for triage of the patient or the patient can present directly to ROC where a hand specialist is always present.

Treatment

Thorough knowledge of anatomy, hand and microsurgical techniques is the key in dealing with open hand injuries that frequently involve multiple structures. This is why training in a specialized hand fellowship program for one year to be a certified hand surgeon is vital for the best possible outcomes to be obtained.

The treatment of an open wound begins with obtaining a clear history to determine the lacerating instrument, the position of the arm and hand during the laceration, the direction and depth of the laceration. The exam will point to the injured tissue and the history will provide the direction the wound should be extended during exploration. The cleaning of the wound, repair of muscle, artery and tendon is done best with the use of magnifying glasses called loupes in a bloodless field by the use of a tourniquet. The improved magnification allows for more accurate determination of the injured and contaminated tissue allowing an accurate repair. From the wrist to the finger tips, the use of a microscope permits the most accurate repair of all tissue structures, particularly the arteries, veins and nerves.

Tetanus is updated if it has been longer than 10 years since receiving a tetanus shot or if the wound is a dirty wound, then the tetanus is updated if it has been five years since receiving a tetanus shot. This is to avoid the danger of acquiring gas gangrene that can be deadly. The use of oral antibiotics for one week after a repair is used as a prophylaxis to avoid the risk of infection. Special splints are applied after surgery for protection and prevent certain movements the patient might inadvertently do. The injured extremity after surgery must be elevated to at least heart level to avoid swelling of the limb that causes moderate pain, cut off the blood supply and delay wound healing. Depending on whether the wound is superficial or deep and the association of other injuries, your surgeon at ROC will elaborate a treatment plan. Please refer to the section on Tendon, Nerve and Vessel Injuries or Fractures to review the pertinent information if you wish to learn more about it.